Physicians need to be part of the overall wellness process

After nearing the brink of political collapse, Congress and the President reached agreement on a plan for deficit reduction. Part of the agreement is that a “super committee”will cut an additional $1.5 trillion from the federal budget. Cuts are being considered for a range of programs, including Medicare. As director of a wellness program for retirees, however, I remain acutely concerned about the impact Medicare cuts will have on our parents and grandparents and the message we are sending about our priorities. Our retirees faithfully paid their Medicare payroll taxes throughout their working careers, and with the stroke of a pen we will tell them it doesn’t exist. Reducing their benefits or payments for their care undoubtedly hurts their health and our economy, and suggests that we put foreign debt over debt to our seniors.

Under the terms of the deficit reduction plan, the 12-member select committee is to reduce the 10-year deficit by $1.5 trillion by November 2011. If the committee is unable to develop a plan or Congress rejects their proposal or the President vetoes the recommendations, spending would be cut by $1.2 trillion automatically including a 2% across the board cut to all Medicare providers. If such an undirected cut in expenditures comes to pass, surely muscle and fat will be cut, and the long term progress we are making in seniors’ health will be hampered.

Our primary goal should be to transform our healthcare system from a disease focused model of coverage to a true health-oriented system. Our program provides health education and chronic disease monitoring services to retirees of southeastern Massachusetts and northern Rhode Island, and has led to steady and marked improvements in enrollees’ health. Our program, however, does not work in isolation. It complements the improved access to physicians and therapies that Medicare provides. Cutting Medicare would surely hurt retirees’ health by directly reducing their access to care and medications and would likely eliminate the added-value of programs like ours across the country.

A recent Center for Disease Control and Prevention study pointed out that providing health care for an older American costs 3 to 5 times more than for an individual under age 65. As the population ages, the nation’s health care spending is projected to increase 25% by 2030. Currently, about 80% of older Americans are living with at least one chronic condition. This latter statistic coincides directly with surveys of our members. In a review of the data from our wellness and screening program held last May, 81% reported being diagnosed with either diabetes, hypertension or elevated cholesterol. Of those, 27% reported having one condition, 39% with two conditions and 15% having all three conditions. Also of those who participated in our program, 76% reported taking medication for the three conditions. This broke down into 28% taking medication for one condition, 38% for two of the three conditions and 10% taking medication for all three conditions. This level of disease morbidity points to the need to maintain rather than cut funding for health care services. Continued funding will keep our seniors involved in the community and ambulatory. Not only will they benefit, the community will benefit and we will reduce long-term costs by keeping people in their homes and out of the hospital or nursing home.

There are two interrelated strategies needed to achieve healthcare reform. One is to assure our members keep up with their treatment plans, including their medications which help keep them alive and maintain an active lifestyle. Passage of Medicare Part D has significantly enhanced our enrollees’ access to life-saving medications and helped many adhere with recommended drug therapy regimens by reducing the economic barriers. Moreover, the elimination of the “doughnut hole” in Part D coverage that is part of the Affordable Care Act has also helped maintain access to important therapies for our retired citizens.

Along with dramatically enhancing access and adherence to medications, researchers at Harvard Medical School found that Medicare Part D was associated with lower non-drug medical costs for seniors compared with what would have been expected had Part D not been created (JAMA 2011). Most of the drop was the result of reductions in high-cost inpatient and nursing home care. This study is particularly important because it verifies what many have expected and discussed for years, but few verified: Improved access to medications drives costs down. Although we have not done a parallel survey with our members, they report similar cost savings following enrollment in Part D. And despite its successes and the short-sighted nature of such proposals, Medicare Part D is being targeted as part of the deficit reductions.

As we work through the reduction process, it will be important for committee members to recognize that maintenance of adequate adherence to drug therapies is only part of an effective care plan. Patients also need a primary care physician who leads their wellness team. Drastic cuts in Medicare physician fees would hamper attempts to build a wellness team with the physician as the leader.

A May online survey of more than 9,000 physicians conducted by the American Medical Association found that practices already are making changes based on underpayments from Medicare. About 17% of all physicians who accept Medicare patients are restricting the number of beneficiaries they see. And more than 30% of respondents who were identified as primary care physicians said they limit their Medicare patient load. For both sets of physicians, the top two reasons they cited were that Medicare reimbursement rates were too low and that the constant threat of cuts made Medicare an unreliable payer. More cuts to Medicare are sure to continue tipping the balance away from patients, putting care further out of reach for many and striking a serious blow to our ongoing wellness efforts.

From our wellness program’s inception, we have solicited opinions from our members regarding how we can better serve their health needs. One clear message is that physicians need to be part of the overall wellness process and that we must integrate our community based services with the in-office care they regularly receive as part of their Medicare benefits. Our program has evolved whereby we are now testing and recruiting new wellness program members through the primary care physician’s office. It is a model of wellness patterned after the Patient Centered Medical Home (PCMH) as endorsed by the Academy of Family Practice.

Our approach is one where health care delivery is team based and occurs at home, in the community and in medical offices. Only by shifting from treating chronic diseases in high-cost settings like hospitals will we achieve true cost savings and bend the proverbial “cost curve.” Furthermore, we need to put our resources behind prevention and cost effective therapies rather than reactive, acute, high-cost care. Effective and efficient models of care such as these, not cuts, should be the future of Medicare.

To be clear, inefficiencies in the Medicare program need to be identified and eliminated along with a concerted effort to root out fraud. And improved information systems that support up-to-date treatment plans grounded in science will be critical for improving efficiency. However, when confronting challenging chronic diseases, much depends on access to the right therapies and a physician-led team that can follow up with community based resources. The exodus of primary care physicians that would results from additional cuts in Medicare would be a serious blow to patients and the progress they have made to date.

The “super committee” has a once in a lifetime opportunity to tell our retirees that their long years of hard work will not go unrecognized — the investments they made in Medicare will be there when they need them. Let’s not impede the progress we made with short-term cost savings that will eventually limit our options for true long-term reform.